Precision Transformation Experience

PTE - Client Initial Assessment

Complete this guided intake to share your goals, current wellbeing, and preferences for an initial assessment—no trauma details required.
Contact & Appointment Details
Full Name

First NameMiddle NameLast Name
Preferred Name
Pronouns
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method

Other
Preferred Appointment Date and Time
Welcome, Disclaimer & Adult Confidentiality
Welcome and Disclaimer
I understand this form is for screening and information-gathering only, not a medical or mental health diagnosis, and I acknowledge the confidentiality limits for adults
Personal Story & Current Life
What brings you in today?
What current concerns are you experiencing?
What recent changes or events have affected you?
Is there anything else about your current life or context you would like to share?
Well-Being 1–10 Ratings
Hope

1

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10

1 is Very low, 10 is Very high
Happiness

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10

1 is Very low, 10 is Very high
Anxiety

1

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10

1 is Very low, 10 is Very high
Stress

1

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1 is Very low, 10 is Very high
Confidence

1

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10

1 is Very low, 10 is Very high
Motivation

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1 is Very low, 10 is Very high
Energy

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1 is Very low, 10 is Very high
Self-worth

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1 is Very low, 10 is Very high
Sleep quality

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10

1 is Very poor, 10 is Excellent
Physical health

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1 is Very poor, 10 is Excellent
Readiness for change

1

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10

1 is Not ready, 10 is Fully ready
Screening Only: PHQ-9-Style & GAD-7-Style
Depressive Symptoms Screening (Past 2 Weeks Only)
Anxiety Symptoms Screening (Past 2 Weeks Only)
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading or watching television
Moving or speaking so slowly that other people could have noticed, or being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Physical Health, Sleep, Nutrition & Medications
Current physical health concerns

Other
If yes, please describe your main physical health concern
How long has this concern been present and how is it currently managed?
Sleep difficulties you are experiencing

Other
If yes, describe your sleep pattern, typical duration, and any factors that affect it
Nutrition or eating patterns of concern

Other
Please describe any current medications, supplements, or medical considerations your clinician should know about
Is there anything else about your physical health, sleep, or eating patterns that would be important to understand?
Alcohol & Substance History
Do you currently use alcohol?
Do you currently use any substances other than alcohol?
If yes, what types do you use?

Other
How often do you use alcohol or other substances?
When was your most recent use, and what was it?
Have alcohol or substance use ever caused any concerns or impacted your health, mood, work, relationships, or safety?
Relationships & Support
Tell us about your current home and family situation
Who are the main people you rely on for support?
How supported do you feel by the people around you?
Are there any current relationship stresses or conflicts you want us to know about?
Strengths, Interests, Identity & Values
What personal strengths are you most proud of?
Which strengths best describe you?

Other
What interests, hobbies, or activities help you feel most like yourself?
How do you describe your identity or the communities you feel connected to?
What core values matter most to you in your life right now?
Wheel of Life
Career / Work

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10

1 is Low Satisfaction, 10 is High Satisfaction
Health / Physical Well-Being

1

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10

1 is Low Satisfaction, 10 is High Satisfaction
Relationships / Family

1

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1 is Low Satisfaction, 10 is High Satisfaction
Friends / Social Life

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1 is Low Satisfaction, 10 is High Satisfaction
Finances

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1 is Low Satisfaction, 10 is High Satisfaction
Home / Environment

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1 is Low Satisfaction, 10 is High Satisfaction
Fun / Recreation

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1 is Low Satisfaction, 10 is High Satisfaction
Personal Growth / Fulfillment

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1 is Low Satisfaction, 10 is High Satisfaction
Music Preferences & Therapeutic Song Interest
Learning & Communication Preferences
Comfort With Therapeutic Practices & Assignments
Journaling

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1 is Not comfortable, 10 is Very comfortable
Movement or gentle exercise

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1 is Not comfortable, 10 is Very comfortable
Breathing exercises

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1 is Not comfortable, 10 is Very comfortable
Guided visualization

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1 is Not comfortable, 10 is Very comfortable
Role-play or practicing conversations

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1 is Not comfortable, 10 is Very comfortable
Using technology or apps for support

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1 is Not comfortable, 10 is Very comfortable
Completing between-session assignments

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1 is Not comfortable, 10 is Very comfortable
Goals, Barriers, Readiness & One Small Action
What are your main goals right now?

Other
What barriers or challenges are getting in the way?
How ready do you feel to make a change right now?

1

2

3

4

5

6

7

8

9

10

1 is Not ready, 10 is Very ready
What is one small, concrete action you are willing to take before our next session?
What would help you succeed with that action?
Optional Uploads
Lab Results

Cancelof
Prior Evaluations

Cancelof
Permissions, Consent & Signature
Communication permissions for Leslie

Other
Preferred contact methods

Other
Consent to receive SMS or email messages from Leslie
Typed name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Electronic signature
Should be Empty:

PTE - Client Initial Assessment

Contact & Appointment Details

Welcome, Disclaimer & Adult Confidentiality

Personal Story & Current Life

Well-Being 1–10 Ratings

Screening Only: PHQ-9-Style & GAD-7-Style

Physical Health, Sleep, Nutrition & Medications

Alcohol & Substance History

Relationships & Support

Strengths, Interests, Identity & Values

Wheel of Life

Music Preferences & Therapeutic Song Interest

Learning & Communication Preferences

Comfort With Therapeutic Practices & Assignments

Goals, Barriers, Readiness & One Small Action

Optional Uploads

Permissions, Consent & Signature